Dual Loyalty: Should Physicians Always Prioritize The Patient?

A physician shall owe his patients complete loyalty and all the resources of his science.

— WMA International Code of Medical Ethics

Although these principles are grounded unmistakably in both ancient and modern texts across the globe, there is growing recognition that doctors are too often placed in situations where it is difficult for them to fulfill loyalty obligations to their patients. Opposing and competing obligations to third parties, such as employers, governments, and insurers, often test the devotion that health professionals are required to give to their patients. Such conflicts are generally identified as “dual loyalty” issues because the health professional is torn between two different players which often have different or competing aims and objectives. In many cases, health professionals who succumb to the pressure to fulfill third party needs at the expense of their patients needs end up violating the human rights of the very person who is entitled to the health professional’s strongest loyalty.

An army doctor is charged with managing the care and well-being of a unit under enemy attack. Although all doctors, including military doctors, are required to treat the health of their patients as their primary concern, the battlefield commander places immense pressure on the doctor to return men to combat before they are mentally and/or physically fit. The doctor recognizes that many of the men are still suffering from painful and debilitating wounds as well as PTSD, but he fears that keeping them from battle could jeopardize the safety and survival of the entire unit because the enemy is numerous. The doctor is unsure of whether to abide by his loyalty obligation to provide the best possible care to his patient or to obey the orders of his military commander, who represents both his employer and the government.

Closed environments, such as prisons, jails, detention centers, mental health facilities, and the military, are the most susceptible to breeding dual loyalty conflicts because security concerns tend to run high while transparency and monitoring mechanisms are generally lacking or altogether absent. Additionally, there is often ambiguity, sometime deliberately, about the health professional’s role in closed institutions. Health professionals working in these environments often find it difficult to provide the best possible care for their patients because they feel pressure to participate in institutional security, cost cutting, and helping to meet other institutional objectives.

The loyalty conflicts resulting from third party pressure may be express (e.g. the military commander orders the doctor to clear patients for battle) or implied (the commander frequently reminds the doctors that the enemy outnumbers them), and they may be real (the commander is indeed putting pressure on the doctor), or perceived (the doctor feels it is his responsibility to get the soldiers back on the battleground, even though the commander has not communicated with him at all). However, regardless of the form the pressure takes, and even if it is only perceived to be real by the doctor, it still has the potential to distract him from providing the best possible care to his patients. Situations like the one described above frequently draw health professionals into a moral and ethical maelstrom, where they end up second-guessing what they know to be their first and primary duty: giving patients the best possible care.